P.O. Box 570, Jefferson City, MO 65102-0570 Phone: 800-891-7415

Missouri Department of Health and Senior Services Office of Dental Health P.O. Box 570, Jefferson City, MO 65102-0570 Phone: 800-891-7415

ORAL HEALTH PREVENTIVE SERVICES PROGRAM SUPPLY ORDER FORM PLEASE SUBMIT COMPLETED FORM TO YOUR ORAL HEALTH CONSULTANT AT LEAST 4 WEEKS PRIOR TO EVENT DATE

Jeffrey Bellamy - [email protected] THESE SUPPLIES ARE BEING ORDERED FOR THE Beth Cameron – [email protected] FOLLOWING SCHOOLS: Grades Number children Date of PSP Audrey Hendee - [email protected] Enter school name below: Ann Hoffman - [email protected] participating: participating: event: Example: ABC Elementary Example: K-5 Molly McBride-Mooty - [email protected] 1. DATE: CONTACT PERSON: 2. 3. SHIP TO (AGENCY/SCHOOL): 4. 5. SCHOOL DISTRICT NAME: (if applicable) 6. 7. STREET ADDRESS: (Shipments by UPS will not deliver to PO Box) 8. 9. CITY: MO ZIP CODE: 10. 11. COUNTY: 12. 13. PHONE: 14. EMAIL: 15. Total Children Participating Shipment could arrive in 1 or more boxes and on separate days. AMOUNT ITEM DESCRIPTION REQUESTED 11375 DISPOSABLE MIRRORS (1 PER CHILD) RECOMMENDED FOR ORAL SCREENINGS

11166 FLUORIDE VARNISH-FLAVORED (1 PER CHILD)

11013 TOOTHBRUSHES – SMALL ( PRE-SCHOOL-2ND Grade)

11164 TOOTHBRUSHES – REGULAR (3RD – 12TH Grade)

11017 FRESHMINT FLUORIDE TOOTHPASTE (1 PER CHILD)

11024 FLOSS (4TH -12TH Grade ONLY)

11079 SCREENING FORMS (1 PER CHILD) MUST ORDER CANNOT USE PREVIOUS YEARS SCREENING FORMS

RETURN ENVELOPES for 150 screening forms or less (1 PER FACILITY )

11330 RETURN MAILING BOXES for 150 screening forms or more (1 PER FACILITY)

11038 LAMINATED SCREENING REFERENCE GUIDE (1 PER SCREENER)

11195 ORAL HEALTH EDUCATION CARDS – (1 PER CHILD) –English only

85 BRUSHING BASICS ACTIVITY BOOK – English (pre K – 2ND grade)

130 BRUSHING BASICS ACTIVITY BOOK – Spanish (pre K – 2ND grade)

102 BRUSHING BASICS BOOKMARK - English

518 BRUSHING BASICS BOOKMARK – Spanish

103 DON’T FORGET TO BRUSH MIRROR CLING - English

519 DON’T FORGET TO BRUSH MIRROR CLING – Spanish

Rev. 12/2017

www.health.mo.gov/PSP